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The Newcastle Protocols for Head-Up Tilt Table Testing in the Diagnosis of Vasovagal Syncope, Carotid Sinus Hypersensitivity, and Related Disorders

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The Newcastle Protocols for Head-Up Tilt Table Testing in the Diagnosis of Vasovagal Syncope, Carotid Sinus Hypersensitivity, and Related Disorders 564 Heart 2000;83:564–569 PRACTICE OBSERVED Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from The Newcastle protocols for head-up tilt table testing in the diagnosis of vasovagal syncope, carotid sinus hypersensitivity, and related disorders R A Kenny, D O’Shea, S W Parry Head-up tilt table testing had been used as an Contraindications to head-up tilt table investigative tool in the pathophysiology of testing orthostatic stress for more than 50 years,1 Head-up tilt table testing is safe with few before the initial demonstration of its utility in reported adverse events.416While there are no the diagnosis of unexplained syncope.2 The reported deaths during tilt testing in the world Westminster group’s landmark study found literature, we are aware of some anecdotal that 67% of patients with otherwise unex- reports of fatal outcome during tilt testing, and plained syncope demonstrated a vasovagal caution should be applied as follows: relative reaction during head-up tilt, compared to only contraindications include clinically severe left 10% of healthy controls.2 Head-up tilt table ventricular outflow obstruction, critical mitral testing has since evolved into the diagnostic test stenosis, and patients in whom low organ per- of choice in vasovagal syncope and related dis- fusion pressures may compromise end artery orders, but there are still wide variations in the supplied tissue, as in severe proximal coronary protocols used in various centres, hampering artery and cerebrovascular stenosis. Where not only the clinical utility of the test but the such pathology is suspected, caution should be adequate assessment of research activity in the exercised regarding the duration and degree of http://heart.bmj.com/ field. The following protocols are based on the hypotension allowed during tilt testing. Con- available evidence and our experience in this traindications to isoprenaline provoked tilt field and, as such, provide a practical and table testing are discussed in the appropriate standardised approach. They are intended for section. use by cardiologists and other physicians with an interest in this topic, and hence assume some prior knowledge of the procedure. A more detailed description and justification for Head-up tilt table test methodology on September 29, 2021 by guest. Protected copyright. the protocols is readily available.34 The conditions under which the head-up tilt test are carried out critically influence out- come, hence these will be examined in detail. Indications for head-up tilt table testing PATIENT PREPARATION Head-up tilt table testing should be considered Patients, in particular those over 60 years old, in patients with recurrent syncope or presyn- should be fasted for no more than two hours cope, or in high risk patients with a history of a before the procedure in order to avoid the con- single syncopal episode (for example, those founding eVects of relative dehydration and suVering serious injury during syncope or hypotension.417 The procedure should be those experiencing syncope while driving) explained to the patient who should rest supine where no other cause for symptoms is sug- for 20–45 minutes.18–20 A longer period is Cardiovascular gested by initial history, examination or cardio- particularly important if intravascular instru- Investigation Unit, 19 21 Victoria Wing, Royal vascular and neurological investigations. Tilt mentation is required. Where practicable, Victoria Infirmary, table testing may also be useful in the drugs aVecting the cardiovascular and auto- Queen Victoria Road, assessment of elderly patients with recurrent, nomic nervous systems and those likely to Newcastle upon Tyne unexplained falls.5 The head-up tilt table test aVect intravascular volume should be discon- NE1 4LP,UK may also have a role in the diVerential diagno- tinued for at least five half lives before the test17 R A Kenny sis of convulsive syncope,5–7 orthostatic unless they are implicated as an attributable D O’Shea 8 SWParry hypotension, the postural orthostatic tachy- cause of syncope, in which case testing should cardia syndrome,9 psychogenic10 and be done on medications. While in the head-up Correspondence to: hyperventilation11 12 syncope, and carotid sinus tilt position, the patient should be instructed to Professor Kenny hypersensitivity.13–15 The Newcastle protocol avoid movement of the lower limb musculature email: [email protected] for carotid sinus massage is detailed later in this and joints in order to maximise venous Accepted 7 January 2000 article. pooling.417 Head-up tilt table testing 565 mise stimuli aVecting autonomic nervous function, the test should occur in a quiet, dimly lit room at a comfortable temperature. Ad- Heart: first published as 10.1136/heart.83.5.564 on 1 May 2000. Downloaded from vanced resuscitation equipment should be immediately available and to the standard required in exercise tolerance testing facilities.4 The test should be continuously supervised by a physician, nurse or technician experienced in the management of the test and its potential complications. If not directly supervised by such, a physician experienced in advanced car- diac life support should be immediately available at all times. TILT TABLE ANGLE AND DURATION OF THE HEAD-UP TILT TABLE TEST Tilt table angle and the duration of the tilt test are crucial determinants of its positivity, sensi- 42324 Figure 1 Continuous digital photoplethysmography tivity, and specificity. Tilt angles of be- (Finapres, Ohmeda) tween 60° and 80° are optimal in provoking suYcient orthostatic stress without increasing 42024 EQUIPMENT, MONITORING, AND ENVIRONMENT the incidence of false positive results and The tilt table should be of the foot plate are recommended by most authorities.4524Our support type. Whether mechanically or electri- own practice utilises a 70° angle for head-up tilt cally powered, it should allow rapid achieve- table testing.19 25 ment of the upright posture and allow Duration of the drug free, passive tilt test has calibrated tilt angles of between 60° and 80°; been reported from 10–60 minutes by various rapid and smooth resumption of the supine centres.5 19 20 24–32 There are little hard data position should be easily achievable. Electro- available on the relative merits of diVerent drug cardiographic monitoring should occur con- free, passive tilt test periods, though most tinuously during symptoms or haemodynamic recent reports favour prolonged passive changes and every minute otherwise. Blood head-up tilt (30–45 minutes).41920 Fitzpatrick pressure monitoring should be of the continu- and colleagues noted a significant increase in ous, non-invasive, beat-to-beat variety (for the number of false negative results with example, digital photoplethysmography, Fin- shorter tilt periods.20 The mean time to syncope in their patients was 24 minutes20; apres, Ohmeda, Wisconsin (fig 1), or Port- http://heart.bmj.com/ apres, TNO Biomedical, Amsterdam), since assuming a normal distribution plus two sphygmomanometric measures are insensitive standard deviations, a duration approaching 45 to rapid changes in blood pressure. The newly minutes would be optimal at present,424 and published classification of the haemodynamics our own practice is to continue the tilt test for of vasovagal syncope by Brignole and 40 minutes or until symptoms supervene. colleagues,22 which has important implications for both clinical practice and research, is Newcastle protocols overview dependent on continuous and detailed blood The Newcastle protocols for head-up tilt pressure monitoring, making beat-to-beat as- testing in the diagnosis of vasovagal syncope on September 29, 2021 by guest. Protected copyright. sessment essential, though sphygmomanomet- are summarised in table 1. Patient preparation, ric measures continue to be used. The environment, and monitoring should proceed Portapres device has the added advantage of as described above. Termination of the test derived measures of stroke volume, cardiac should occur immediately positivity criteria are output, total peripheral resistance, etc, but is achieved, or if patient discomfort, significant unfortunately rather more costly, while Fin- arrhythmia or other adverse event develops. apres is no longer in production. Routine Blood pressure is recorded at one minute intra-arterial blood pressure monitoring is not intervals, with ECG recordings made at one advised. Blood pressure should similarly be minute intervals or continuously during symp- recorded continuously (or as frequently as is toms or haemodynamic derangements. Intra- practicable) during symptoms and at one venous cannulation is avoided in all but the minute intervals otherwise. In order to mini- isoprenaline protocols to preclude its adverse eVects on specificity.19 21 Table 1 Summary of Newcastle protocols for head-up tilt table testing DRUG FREE PASSIVE HEAD-UP TILT Tilt test description Method The patient is rested supine for 20 minutes Passive drug free tilt 40 min at 70° before the test, then tilted upright for 40 min- Isoproterenol (µg) tilt* 5 min tilt, 5 min supine 5 min 1 µg/min supine, 5 min 1 µg/min ° at 70° Infusion discontinued, supine 2 min 5 min 3 µg/min utes at an angle of 70 . supine, 5 min 3 µg/min at 70° GTN tilt 2 metred doses sublingual GTN spray supine 5 min supine PHARMACOLOGICAL PROVOCATION HEAD-UP TILT then 20 min at 70° TESTING *Based on Almquist et al.25 Isoprenaline head-up tilt test Patients should remain supine for 20 minutes before testing. Isoproterenol and GTN tilts should The patient remains supine for 20 minutes, follow non-diagnostic passive drug free tilt where history is suggestive of vasovagal syncope. Tilt ° should be terminated if symptom reproduction with concomitant hypotension/bradycardia or and is then tilted to 70 for five minutes. The adverse event develops. See text for further details. supine position is again assumed for five 566 Kenny, O’Shea, Parry minutes’ re-equilibration. Isoprenaline is then Miscellaneous infused at a rate of 1 µg/min for five minutes Edrophonium,37 clomipramine,38 and adeno- 39–41 supine, then five minutes at 70° tilt.
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